OBBBA Rural Health Transformation Program expires after a three-year pilot, with no guaranteed successor

The One Big Beautiful Bill Act created the Rural Health Transformation Program, a Medicaid waiver program that provides enhanced federal matching funds to rural states that voluntarily redesign their Medicaid delivery systems. The program expires October 1, 2030, after a three-year authorization window. Rural hospitals — which face the highest closure rates in the country — received temporary federal relief through the program. Without reauthorization, rural states lose access to the enhanced matching rate and must either absorb higher state costs or restructure benefits. The program's expiration will test whether Congress prioritizes rural healthcare access in the context of broader Medicaid restructuring debates.